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Billig S, Hein M, Uhlig M, Schumacher D, Thudium M, Coburn M, Weisheit CK. [Anesthesia for aortic valve stenosis : Anesthesiological management of patients with aortic valve stenosis during noncardiac surgery]. DIE ANAESTHESIOLOGIE 2024; 73:168-176. [PMID: 38334810 PMCID: PMC10920418 DOI: 10.1007/s00101-024-01380-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/10/2024]
Abstract
Aortic valve stenosis is a common condition that requires an anesthesiologist's in-depth knowledge of the pathophysiology, diagnostics and perioperative features of the disease. A newly diagnosed aortic valve stenosis is often initially identified from the anamnesis (dyspnea, syncope, angina pectoris) or a suspicious auscultation finding during the anesthesiologist's preoperative assessment. Interdisciplinary collaboration is essential to ensure the optimal management of these patients in the perioperative setting. An accurate anamnesis and examination during the preoperative assessment are crucial to select the most suitable anesthetic approach. Additionally, a precise understanding of the hemodynamic peculiarities associated with aortic valve stenosis is necessary. After a short summary of the overall pathophysiology of aortic valve stenosis, this review article focuses on the specific anesthetic considerations, risk factors for complications, and the perioperative management for noncardiac surgery in patients with aortic valve stenosis.
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Affiliation(s)
- Sebastian Billig
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Marc Hein
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Moritz Uhlig
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - David Schumacher
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Marcus Thudium
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Mark Coburn
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Christina K Weisheit
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
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Hariri EH, El Halabi J, Kassis N, Al Hammoud MM, Badwan OZ, Layoun H, Kassab J, Al Shuab W, Bansal A, Farwati M, Harb SC, Popović ZB, Svensson L, Menon V, Kapadia SR. Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2024; 17:1-12. [PMID: 37498256 DOI: 10.1016/j.jcmg.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS). OBJECTIVES The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS. METHODS This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex. RESULTS The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men. CONCLUSIONS Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.
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Affiliation(s)
- Essa H Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jessica El Halabi
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Kassis
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mazen M Al Hammoud
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Osamah Z Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joseph Kassab
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wael Al Shuab
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - Agam Bansal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Medhat Farwati
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lars Svensson
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Shen M, Tastet L, Capoulade R, Bédard É, Arsenault M, Clavel MA, Pibarot P. Determinants of Aortic Stenosis Progression in Bicuspid and Tricuspid Aortic Valves. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:184-192. [PMID: 37969929 PMCID: PMC10642113 DOI: 10.1016/j.cjcpc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/19/2022] [Indexed: 11/17/2023]
Abstract
Background Bicuspid aortic valve (BAV) is associated with a faster progression of aortic stenosis (AS). Whether the determinants of AS progression are the same or different in patients with BAV vs tricuspid aortic valve (TAV) is unknown. The aim of this study was to identify the factors associated with the progression of AS in patients with BAV vs patients with TAV. Methods Patients with AS were prospectively recruited in the Metabolic Determinants of the Progression of Aortic Stenosis (PROGRESSA) study (ClinicalTrials.gov Identifier: NCT01679431). The haemodynamic progression rate of AS was assessed by the annualized progression rate of peak aortic jet velocity (Vpeak). Univariable and multivariable linear regression analyses were used to identify the factors associated with a faster progression of AS in patients with BAV vs patients with TAV. Results There were 79 patients with BAV and 208 patients with TAV. The baseline severity of AS was similar between the 2 groups of patients as well as the annualized progression rate of AS. In patients with BAV, obesity (β = 0.25, P = 0.04), diabetes (β = 0.26, P = 0.02), and BAV with right-noncoronary cusp fusion (β = 0.29, P = 0.01) were found to be independently associated with a faster progression of AS, whereas in patients with TAV, AS baseline severity (baseline Vpeak, β = 0.14, P = 0.04) and chronic kidney disease (β = 0.16, P = 0.02) were significantly associated with AS progression. Conclusion Factors associated with progression rate of AS are different in BAV and TAV. The main factors associated with a faster progression of AS appear to be obesity, diabetes, right-noncoronary cusp fusion in patients with BAV vs chronic kidney disease in patients with TAV.
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Affiliation(s)
- Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Romain Capoulade
- CHU Nantes, CNRS, INSERM, l’institut du thorax, Université de Nantes, Nantes, France
| | - Élisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec City, Québec, Canada
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Kushiyama A, Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Inada T, Nagao K, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Jinnai T, Morikami Y, Saito N, Minatoya K, Kimura T. Age-Related Differences in the Effects of Initial Aortic Valve Replacement vs. Conservative Strategy on Long-Term Outcomes in Asymptomatic Patients With Severe Aortic Stenosis. Circ J 2020; 84:252-261. [DOI: 10.1253/circj.cj-19-0431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | | | | | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kindai University Faculty of Medicine
| | - Masashi Kato
- Department of Cardiovascular Medicine, Mitsubishikyoto Hospital
| | - Yutaka Hirano
- Department of Cardiology, Kindai University Hospital
| | | | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | | | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | - Takao Kato
- Kyoto University Graduate School of Medicine
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Akihiro Komasa
- Department of Cardiology, Kansai Electric Power Hospital
| | | | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | | | | | | | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine
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Wilson JB, Jackson LR, Ugowe FE, Jones T, Yankey GS, Marts C, Thomas KL. Racial and Ethnic Differences in Treatment and Outcomes of Severe Aortic Stenosis. JACC Cardiovasc Interv 2020; 13:149-156. [DOI: 10.1016/j.jcin.2019.08.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/19/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
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Bois JP, Crowson CS, Khullar T, Achenbach SJ, Krause ML, Mankad R. Progression rate of severity of aortic stenosis in patients with rheumatoid arthritis. Echocardiography 2017; 34:1410-1416. [PMID: 28840957 DOI: 10.1111/echo.13652] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Valvular heart disease is common in patients with rheumatoid arthritis (RA). However, there is uncertainty about how often to perform echocardiographic surveillance in this population. The objective of this study was to assess the progression rate of mild and moderate aortic stenosis (AS) in patients with RA. METHODS A population-based cohort of patients with RA and either mild (2.0-2.9 m/second) or moderate (3.0-3.9 m/second) AS was identified. Demographic, clinical, and echocardiographic data were collected. Annual progression rate of AS was then calculated for the study cohort and the impact of pertinent RA variables on progression rate determined. RESULTS Sixty-eight patients with RA and mild or moderate AS met the inclusion requirements. Peak aortic valve (AV) velocity and mean AV gradient increased during the study period, whereas AV area decreased, consistent with progression of AS (P<.001). Mean (SD) annual increase in peak AV jet velocity was 0.05 m/second (0.01) and in mean AV gradient was 1.0 mm Hg (0.18). Mean annual decrease in AV area was 0.04 (0.01) cm2 . The progression rate of AS was higher in patients with increased erythrocyte sedimentation rates (ESR) (P=.001). CONCLUSIONS The rate of AS progression in the RA population was higher in patients with increased ESR but less than that of the reported rate of AS progression in the general population. Although the cause for this finding is uncertain, these results suggest that patients with RA who have mild or moderate AS should undergo echocardiographic surveillance for disease progression similar to that of the general population.
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Affiliation(s)
- John P Bois
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Cynthia S Crowson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Tamanna Khullar
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sara J Achenbach
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Megan L Krause
- Division of Allergy, Clinical Immunology, and Rheumatology, University of Kansas, Kansas City, Kansas
| | - Rekha Mankad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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7
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Sritharen Y, Enriquez-Sarano M, Schaff HV, Casaclang-Verzosa G, Miller JD. Pathophysiology of Aortic Valve Stenosis: Is It Both Fibrocalcific and Sex Specific? Physiology (Bethesda) 2017; 32:182-196. [PMID: 28404735 PMCID: PMC6148342 DOI: 10.1152/physiol.00025.2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 12/24/2022] Open
Abstract
Our understanding of the fundamental biology and identification of efficacious therapeutic targets in aortic valve stenosis has lagged far behind the fields of atherosclerosis and heart failure. In this review, we highlight the most clinically relevant problems facing men and women with fibrocalcific aortic valve stenosis, discuss the fundamental biology underlying valve calcification and fibrosis, and identify key molecular points of intersection with sex hormone signaling.
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Affiliation(s)
- Yoginee Sritharen
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Grace Casaclang-Verzosa
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Jordan D Miller
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota;
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
- Department of Surgery, Mayo Clinic, Rochester, Minnesota; and the
- Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota
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8
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Vanichsarn C, Siegel RJ. Fool me once, fool me twice: hypertrophic cardiomyopathy with aortic stenosis. Am J Med 2015; 128:1076-9. [PMID: 26021815 DOI: 10.1016/j.amjmed.2015.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/19/2015] [Accepted: 05/19/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Christopher Vanichsarn
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif.
| | - Robert James Siegel
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif
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Ersboll M, Schulte PJ, Al Enezi F, Shaw L, Køber L, Kisslo J, Siddiqui I, Piccini J, Glower D, Harrison JK, Bashore T, Risum N, Jollis JG, Velazquez EJ, Samad Z. Predictors and progression of aortic stenosis in patients with preserved left ventricular ejection fraction. Am J Cardiol 2015; 115:86-92. [PMID: 25456876 DOI: 10.1016/j.amjcard.2014.09.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/26/2014] [Accepted: 09/26/2014] [Indexed: 11/28/2022]
Abstract
We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.
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Affiliation(s)
- Mads Ersboll
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark
| | - Phillip J Schulte
- The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Fawaz Al Enezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Linda Shaw
- The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Lars Køber
- The Heart Center, Department of Cardiology, University of Copenhagen, Rigshospitalet, Denmark
| | - Joseph Kisslo
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Irfan Siddiqui
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jonathan Piccini
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Donald Glower
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - J Kevin Harrison
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Thomas Bashore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Niels Risum
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - James G Jollis
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Eric J Velazquez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; The Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Zainab Samad
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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Abstract
Degenerative, calcific valvular aortic stenosis (AS), caused by an active process of atherosclerosis, calcification and ossification, is the most common cause of AS in industrialized nations. The prevalence of calcific AS is age-dependent, and thus is expected to increase due to demographic aging of the global population. It is well recognized that severe AS carries a poor prognosis if left untreated. Despite this recognition, many patients are inappropriately denied surgery because of perceived risk. This article will examine the etiology, prevalence, and current trends in the treatment of degenerative AS focusing on indications for surgical aortic valve replacement.
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Affiliation(s)
- Jeremy J Thaden
- Division of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Division of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, MN.
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Aronow WS. A review of the pathophysiology, diagnosis, and treatment of aortic valve stenosis in elderly patients. Hosp Pract (1995) 2013; 41:66-77. [PMID: 24145591 DOI: 10.3810/hp.2013.10.1082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elderly patients experiencing valvular aortic stenosis (AS) show an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular diseases. Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS in patients. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS upon physical examination of the patient. Doppler echocardiography is used to diagnose the severity of patient AS. In the article, indications for aortic valve replacement (AVR) in patients, the use of warfarin after AVR in patients with mechanical prostheses, and the use of aspirin or warfarin after AVR in patients with bioprosthesis are discussed. Transcatheter aortic valvular replacement should be performed in non-operable patients with symptomatic severe AS to improve their survival and quality of life rather than using regular medical management of the condition.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York.
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12
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Choosing between velocity-time-integral ratio and peak velocity ratio for calculation of the dimensionless index (or aortic valve area) in serial follow-up of aortic stenosis. Int J Cardiol 2013; 167:1524-31. [DOI: 10.1016/j.ijcard.2012.04.105] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 04/10/2012] [Accepted: 04/14/2012] [Indexed: 11/22/2022]
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Kearney LG, Ord M, Buxton BF, Matalanis G, Patel SK, Burrell LM, Srivastava PM. Progression of aortic stenosis in elderly patients over long-term follow up. Int J Cardiol 2012; 167:1226-31. [PMID: 22483251 DOI: 10.1016/j.ijcard.2012.03.139] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 02/07/2012] [Accepted: 03/15/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND The natural history of aortic stenosis (AS) in elderly patients remains poorly defined. In an elderly cohort over long-term follow-up, we assessed: 1) rates and predictors of hemodynamic progression and 2) composite aortic valve replacement (AVR) or death endpoint. METHODS Consecutive Department of Veterans' Affairs patients with AS (>60 years) were prospectively enrolled between 1988 and 1994 (n=239) and followed until 2008. Patients with ≥ 2 trans-thoracic echocardiograms >6 months apart were included in the progression analysis (n=147). Baseline demographics, comorbidities and echocardiography parameters were recorded. Follow-up was censored at AVR/death. RESULTS The age of patients was 73 ± 6 years; 82% were male. Baseline AS severity was mild (67%), moderate (23%) and severe (10%). Follow-up was 6.5 ± 4 years (range: 1-17 years). Annualized mean aortic valve gradient progression rates were: mild AS 4 ± 4 mmHg/year; moderate AS 6 ± 5 mmHg/year and severe AS 10 ± 8 mmHg/year (p<0.001). Five-year event-free survival was 66 ± 5%, 23 ± 7% and 20 ± 10% for mild, moderate and severe AS respectively. Progression to severe AS occurred in 35% and 74% of patients with mild and moderate AS respectively. Independent predictors of rapid progression were: baseline AS severity (per grade) (OR 2.6, p=0.001), aortic valve calcification (per grade) (OR 2.1, p=0.01), severe renal impairment (OR 4.0, p=0.04) and anemia (OR 2.3, p=0.05). CONCLUSIONS In elderly patients, hemodynamic progression of AS is predicted by AS severity, renal function, aortic valve calcification and history of anemia. These factors identify patients at high risk of rapid hemodynamic progression, for whom more frequent clinical and echocardiographic surveillance is advisable.
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Affiliation(s)
- L G Kearney
- Department of Cardiology, Austin Health, VIC, Australia.
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Ngo DT, Sverdlov AL, Willoughby SR, Nightingale AK, Chirkov YY, McNeil JJ, Horowitz JD. Determinants of Occurrence of Aortic Sclerosis in an Aging Population. JACC Cardiovasc Imaging 2009; 2:919-27. [DOI: 10.1016/j.jcmg.2009.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 03/09/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
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Aortic stenosis. ACTA ACUST UNITED AC 2008; 33:174-83. [PMID: 18025609 DOI: 10.1007/s12019-007-8021-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 11/30/1999] [Accepted: 07/16/2007] [Indexed: 10/22/2022]
Abstract
Patients with aortic stenosis (AS) have an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular disease and an increased incidence of coronary events and death. Statins may reduce the progression of AS. Angina pectoris, syncope or near syncope, and heart failure are the three classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the presence and severity of AS. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these four risk factors should be treated with aspirin 75-100 mg daily.
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16
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Kamath AR, Pai RG. Risk factors for progression of calcific aortic stenosis and potential therapeutic targets. Int J Angiol 2008; 17:63-70. [PMID: 22477390 PMCID: PMC2728414 DOI: 10.1055/s-0031-1278283] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Current thought regarding the progression of calcific aortic stenosis (AS) is presented. After summarizing contemporary ideas about AS pathogenesis, the present article examines the factors that may affect disease progression. Data indicate that this process may be accelerated by aortic valve structure, degree of valvular calcification, chronic renal insufficiency and cardiovascular risk factors such as diabetes and dyslipidemia. Finally, the present review discusses potential therapeutic targets to slow AS progression.
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Affiliation(s)
- Ashvin R Kamath
- Loma Linda University Medical Center, Loma Linda, California, USA
| | - Ramdas G Pai
- Loma Linda University Medical Center, Loma Linda, California, USA
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17
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Abstract
Elderly patients with valvular aortic stenosis have an increased prevalence of coronary risk factors, of coronary artery disease, and evidence of other atherosclerotic vascular diseases. Statins may reduce the progression of aortic stenosis (AS). Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the prevalence and severity of AS. The indications for cardiac catheterization and the medical management of AS are discussed. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Other indications for AVR are discussed. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these 4 risk factors should be treated with aspirin 75-100 mg daily.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York 10595, USA.
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18
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Rapid progression of mild to moderate aortic stenosis in patients older than 80 years. J Am Soc Echocardiogr 2007; 20:1243-6. [PMID: 17588711 DOI: 10.1016/j.echo.2007.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the rate of progression of mild and moderate aortic stenosis in patients aged 80 years and older. METHODS In all, 41 patients with mild and moderate aortic stenosis were included and divided into two groups by age: 19 patients aged 80 years and older (mean 84 +/- 4 years), and 21 patients younger than 80 years (mean 66 +/- 6 years). RESULTS The rate of degression of aortic valve area was more rapid in the 80 years and older age group than that in the younger than 80 years age group (-0.05 +/- 0.06 and -0.10 +/- 0.08 cm2/y, P = .014). Univariate and multivariate analysis of the rate of degression of aortic valve area were performed, and age was the only independent predictor of the rate of degression of aortic valve area. CONCLUSION Progression of mild and moderate aortic stenosis in patients aged 80 years and older was more rapid than that in those aged younger than 80 years.
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Maslow AD, Mahmood F, Poppas A, Singh A. Intraoperative Dobutamine Stress Echocardiography to Assess Aortic Valve Stenosis. J Cardiothorac Vasc Anesth 2006; 20:862-6. [PMID: 17138097 DOI: 10.1053/j.jvca.2005.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew D Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence 02903, USA.
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20
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Colli A, Gherli T, Mestres CA, Pomar JL. Degeneration of native and tissue prosthetic valve in aortic position: do statins play an effective role in prevention? Int J Cardiol 2006; 116:144-52. [PMID: 16828903 DOI: 10.1016/j.ijcard.2006.03.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Revised: 02/20/2006] [Accepted: 03/11/2006] [Indexed: 12/28/2022]
Abstract
Degenerative aortic valve stenosis is a common disease in western countries. When it becomes severe, it confers significant morbidity and mortality. Aortic stenosis has been recognized as a complex inflammatory and highly regulated process with histological and immunochemical similarities with the process of atherosclerosis. Hypertension, smoking and diabetes mellitus have consistently been linked to the development of aortic stenosis. Endothelial injury or other processes that contribute to coronary disease may play a role in calcific aortic stenosis. Several observational studies suggests that the key factors of aortic stenosis are lipoproteins and that medical therapies with cholesterol lowering drugs may retard its progression. Similarly, it has been suggested that the process of degeneration of the tissue heart valve has been associated with the same risk factors of atherosclerosis and shares many histological and molecular characteristics. Assuming all this concept, and evaluating the results of a retrospective study it has been suggested to use statin also as medical therapy able to prevent tissue valve degeneration. Randomized controlled clinical trials will be needed to demonstrate the role of lipid intervention to prevent the progression of aortic stenosis and the degeneration of tissue heart valves.
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Affiliation(s)
- Andrea Colli
- Department of Cardiac Surgery, University of Parma, Italy.
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21
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Wash 98195-6422, USA.
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22
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Gillinov AM, Garcia MJ. When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization? Curr Cardiol Rep 2005; 7:101-4. [PMID: 15717955 DOI: 10.1007/s11886-005-0020-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mild to moderate aortic stenosis is a common finding in patients presenting for coronary artery bypass grafting (CABG), and its management is controversial. However, review of available data suggests a surgical strategy for these patients. Recent data demonstrate that 1) progression of aortic stenosis is more rapid in those with leaflet calcification; 2) the addition of aortic valve replacement to CABG in patients with mild to moderate stenosis does not increase hospital mortality when compared with bypass surgery alone; 3) hospital mortality for aortic valve replacement after previous bypass surgery has declined in recent years; 4) aortic valve replacement places the patient at risk for prosthesis-related complications; 5) the limited 10-year survival (competing risk of death) leaves only a minority of individuals with mild aortic stenosis alive and eligible for aortic valve replacement 10 years after bypass surgery; and 6) combined aortic valve replacement and CABG confers a survival benefit in those with moderate aortic stenosis but not in those with mild aortic stenosis. Therefore, in the coronary artery bypass patient with moderate aortic stenosis, leaflet calcification, and life expectancy greater than 5 years, concomitant aortic valve replacement is advised. In contrast, aortic valve replacement is rarely indicated in those with mild aortic stenosis.
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Affiliation(s)
- A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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23
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Liu PY, Tsai WC, Lin CC, Hsu CH, Haung YY, Chen JH. Invasive measurements of pulse wave velocity correlate with the degree of aortic valve calcification and severity associated with matrix metalloproteinases in elderly patients with aortic valve stenosis. Clin Sci (Lond) 2004; 107:415-22. [PMID: 15202929 DOI: 10.1042/cs20040098] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Revised: 05/25/2004] [Accepted: 06/17/2004] [Indexed: 11/17/2022]
Abstract
The aim of the present study was to assess the association between invasive PWV (pulse wave velocity), serum levels of MMPs (matrix metalloproteinases) and the echocardiographic severity and calcification score of degenerative AS (aortic stenosis). We enrolled 30 patients (16 males; age, 61.3±8.2 years) diagnosed with degenerative AS and an additional 30 age- and sex-matched control patients. Invasive PWV methods with a pigtail catheter and double-channel recording were performed in both groups in our catheterization laboratory. We scored the severity of calcification at the AV (aortic valve) during two-dimensional echocardiography. The association between the trans-valvular pressure gradient, the severity of calcification of the AV and the value of PWV were analysed. We also analysed the serum levels of MMP-9, MMP-3 and TIMP-1 (tissue inhibitor of metalloproteinases-1) in these patients. In the group with degenerative AS, mean AV pressure gradients (56.0 compared with 9.5 mmHg; P<0.001) and calcified AV scoring (3.3±1.2 compared with 2.1±0.9; P<0.001) were higher than in the control group. In addition, PWV was faster in the group with degenerative AS (15.5±3.8 compared with 8.0±2.7 m/s; P=0.001). After being adjusted for age, sex, mean blood pressure and left ventricular function, both the AV pressure gradient and the severity of calcification were strongly correlated with PWV (R=0.706, P<0.0001, and R=0.561, P=0.03 respectively). In addition, the serum levels of MMP-9, MMP-3 and TIMP-1 were all significantly higher and correlated with PWV in the group with AS (all P<0.05). With higher serum levels of MMPs and their inhibitors, we found that this invasive measurement of PWV was associated strongly with the pressure gradient and calcification of AV. More advanced degenerative changes in AV was probably associated with more severe aortic arteriosclerosis.
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Affiliation(s)
- Ping-Yen Liu
- Division of Cardiology, Department of Internal Medicine, National Cheng-Kung University Medical Center, Tainan, Taiwan
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Tabet JY, Pascal O, Monin JL. [Echocardiography in elderly patients]. Presse Med 2004; 33:406-12. [PMID: 15105787 DOI: 10.1016/s0755-4982(04)98608-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IN THE CONTEXT OF AGEING: The Doppler echocardiography is a non-invasive technique that permits assessment of the "physiological" ageing of the cardiac and vascular structures, notably including a concentric remodelling of the left ventricle associated with relaxation abnormalities, dilatation of the left atrium, valvular reorganisation and a modification in the large vessels. IN A PATHOLOGICAL CONTEXT: The Doppler echocardiography also detects the various cardiovascular affections related to ageing: valvulopathies, notably calcified aortic stenosis and mitral failure due to mitral anulus calcification or prolapsus of the valve; primary hypertrophic cardiomyopathy or secondary to arterial hypertension or an amyloidosis, and possibly leading to heart failure with spared systolic function, frequent in elderly patients; ischemic cardiopathies that have benefited, as in younger patient, from new echographical stress testing techniques, which safely study the variability in myocardial ischemia. Transoesophageal echography can also be performed in elderly patients, but the indications of this more invasive and less well-tolerated examination must be assessed case by case. It is very useful when an intra-parietal aortic hematoma is suspected or during aortic dissection or infectious endocarditis.
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Affiliation(s)
- J-Y Tabet
- Cardiologue, centre de réadaptation cardiovasculaire des Grand Prés, Villeneuve Saint Denis.
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25
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Sawhney N, Hassankhani A, Greenberg BH. Calcific aortic stenosis in the elderly: a brief overview. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2003; 12:178-82. [PMID: 12732813 DOI: 10.1111/j.1076-7460.2003.02070.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aortic stenosis is the most common valvular lesion in patients above the age of 65. The etiology, presentation, and management of aortic stenosis differs in the elderly compared to younger patients in many ways. Many of the classic physical findings are absent in the elderly, making the diagnosis of critical aortic stenosis more difficult. Due to coexisting morbidity in many elderly patients, there is often a reluctance to recommend aortic valve replacement despite the dismal prognosis of medical therapy. In the following review, the authors discuss the pathophysiology, presentation, and management of aortic stenosis in the elderly.
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Affiliation(s)
- Neil Sawhney
- Division of Cardiology, Department of Medicine, University of California San Diego, UCSD Medical Center, San Diego, CA 92103-8411, USA
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26
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Croft LB, Goldman ME. Calcific aortic stenosis: new pathophysiologic insights and possible new medical therapy. Curr Cardiol Rep 2003; 5:101-4. [PMID: 12583851 DOI: 10.1007/s11886-003-0075-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Aortic stenosis is a progressive disease of aging with serious complications. A common disease of the elderly, it may inexorably progress to stenosis. Recent retrospective studies have correlated risk factors commonly associated with coronary and vascular atherosclerosis with an accelerated rate of aortic valve stenosis. Although hydroxymethyl glutaryl co-enzyme A reductase inhibitor (statin) treatment therapy has been shown to delay the rate of progression of valvular aortic stenosis, the salutary mechanism of the statin may be cholesterol-lowering and/or anti-inflammatory. Further prospective studies are warranted to investigate the mechanism and medical therapy of aortic sclerosis and stenosis.
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Affiliation(s)
- Lori B Croft
- The Zena and Michael Weiner Cardiovascular Institute, Mount Sinai Medical Center, 1 Gustave Levy Place, New York, NY 10029, USA
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27
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Nassimiha D, Aronow WS, Ahn C, Goldman ME. Association of coronary risk factors with progression of valvular aortic stenosis in older persons. Am J Cardiol 2001; 87:1313-4. [PMID: 11377366 DOI: 10.1016/s0002-9149(01)01531-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- D Nassimiha
- Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York, USA
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